GW1-2021-01529_Well Construction - GW1_20210309

RECEIVED
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells (11 Mil
it
r�l aK X 8 L
I.Well Contractor Information: —10
Es
Heath Sawyers intermation Pre
_ TO DESCRIPTION
Well Contractor Name ft. ft.
2436-A
NC Well Contractor Certification Number 15.-OUTER CASING for multi-cased wells ORLINER if a"'lieable
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 62 ft- 16.25 in. 1 #21 1 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)'.
20100120084 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable melt permits(i.e.County,.State, Variance,Injection,etc.) -
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)❑Industrial/Commercial ❑Residential Water Supply(shared) t8 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
El Irrigation 0 ft. 20 ft. Bentonite Pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attachadditional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 62 ft. OVER BURDEN
2-4-2021 62 fit- 405 ft• GRANITE
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: ft. ft.
Wesley Capps ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
6 Pleasant View Drive Mills River, NC 28759 ft. ft.
Physical Address,City,and Zip 21.:REMARKS,
Henderson 9620995820
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field one]at/long is sufficient)
N W � o 2-9-2021
Sig�e ofCerti red Well Con a for Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By,signing this form,1 hereby certify that the well(s)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
//this is a repair,Jill out known well construction information and explain the nature of the
repair under 21 remarks section or on the hack n/'this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Vor multiple injection or non-water supply wells ONLY with the same construction,you can
suhntii oneJbrnt SUBMITTALINSTLTCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr nnuhiple wells list all depths if dfl&rent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 Division of Water Resources,Information Processing Unit,
Illrater level is above casing,use"�" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gp )m 8 Method of test: RIG 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
PILLS
13b.Disinfection type: Amount: 20 well construction to the county health department of the coun where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013